What is the recommended treatment for an immunocompetent adult with uncomplicated genital herpes?

Treatment of Genital Herpes in Immunocompetent Adults

For an immunocompetent adult with uncomplicated genital herpes, the recommended treatment depends on whether this is a first episode, recurrent episode, or requires suppressive therapy. 1

First Episode of Genital Herpes

For initial episodes, treat with valacyclovir 1 gram orally twice daily for 7-10 days, or acyclovir 400 mg orally three times daily for 7-10 days, or acyclovir 200 mg orally five times daily for 7-10 days. 2, 3

• Treatment should be initiated within 72 hours of symptom onset for optimal efficacy, though benefit may still occur if started later 3
• Continue treatment for the full course even if lesions begin to heal earlier 2

Recurrent Episodes (Episodic Therapy)

For recurrent outbreaks, initiate treatment during the prodrome or within 1 day of lesion onset with valacyclovir 500 mg orally twice daily for 5 days. 1

Alternative episodic regimens that are equally effective include:

• Acyclovir 400 mg orally three times daily for 5 days 2, 1
• Acyclovir 800 mg orally twice daily for 5 days 2, 1
• Acyclovir 200 mg orally five times daily for 5 days 2
• Famciclovir 125 mg orally twice daily for 5 days 2, 1

The key to episodic therapy effectiveness is early initiation—patients should be provided with medication or a prescription in advance so they can start treatment immediately at the first sign of prodrome or lesions. 2, 1

Suppressive Therapy (Daily Prevention)

For patients with frequent recurrences (≥6 episodes per year), daily suppressive therapy with valacyclovir 500 mg once daily or 1 gram once daily is recommended. 1, 3

Alternative suppressive regimens include:

• Acyclovir 400 mg orally twice daily 2, 1
• Famciclovir 250 mg orally twice daily 2, 1
• Valacyclovir 250 mg orally twice daily 2

Important considerations for suppressive therapy:

• Reduces recurrence frequency by ≥75% 2, 1
• Valacyclovir 500 mg once daily may be less effective in patients with ≥10 recurrences per year—use 1 gram once daily or twice-daily regimens for these patients 2, 4
• Safety documented for acyclovir up to 6 years and valacyclovir/famciclovir for 1 year 2
• After 1 year of continuous therapy, discuss discontinuation to reassess recurrence rate, as frequency often decreases over time 2, 1
• Suppressive therapy reduces but does not eliminate asymptomatic viral shedding 2

Dosing Equivalence and Convenience

Valacyclovir 1000 mg once daily is equivalent to 500 mg twice daily for episodic treatment, offering a more convenient single-daily-dose option. 5 Valacyclovir provides superior bioavailability compared to acyclovir, allowing less frequent dosing with equivalent efficacy 6

Critical Pitfalls to Avoid

• Never use topical acyclovir—it is substantially less effective than oral therapy 1
• Do not use standard genital herpes dosing for herpes proctitis, which requires higher doses (acyclovir 400 mg five times daily) 7
• Avoid high-dose valacyclovir (8 grams/day) in any patient due to risk of thrombotic thrombocytopenic purpura/hemolytic uremic syndrome 2, 8

Essential Patient Counseling

Patients must understand that genital herpes is a recurrent, incurable viral disease. 1 Key counseling points include:

• Antiviral medications control symptoms but do not eradicate the virus or prevent all recurrences 1
• Abstain from sexual activity when lesions or prodromal symptoms are present 2, 1
• Inform sex partners about having genital herpes 2, 1
• Use condoms during all sexual exposures with new or uninfected partners 2, 1
• Asymptomatic viral shedding can occur and potentially lead to transmission, even without visible lesions 2, 1
• Childbearing-aged women should inform healthcare providers during pregnancy about HSV infection due to neonatal transmission risk 2